Trumpcare: Is it the Right Treatment for what Ails the American Health Care System?

welcome to the Commonwealth Club I'm George Hammond chair of the humanities forum which organized tonight's event I'd like to introduce Claire brindis who came up with the idea for the panel months ago and given the amount of activity of the president in this area the the the content has changed quite often and we're trying to be right up to date as to what's going on but it's very hard to keep track of anything change this morning so she will be and the panel will be just discussing Trump care is it the right treatment for what ails the American healthcare system and Claire as the moderator is the director of Phillip Arlie Institute for Health Policy studies at UC San Francisco and she will introduce the panel members thank you very much for putting this together Claire thank you George and thank you for being a great partner in crime so we're very excited to be here and it is an incredibly important topic and you know you've all heard that Obamacare is a major disaster you've heard that why should we bail out the health care industry and he probably heard but someone said someone you know said nobody knew how complicated health care is well clearly many people didn't know how complicated it is and part of our panel today will be focusing and unpacking some of the complicated aspects of this basically important issue and over the last few months we've been spending a lot of time going through various waves of political action you've heard about repeal and replace then we went through a period of repeal then repeal and delay and currently we're in the period where we were thinking that it should be called keep and destroy hopefully not and part of what we're going to be talking about our some of the ways and approaches that we can do to improve healthcare delivery we've also adjusted to a lot of new words a lot of new vocabulary skinny health plans problem-solvers caucus a variety of bipartisan group work groups who are working on health care reform cost-sharing reduction subsidies imploding health care system and trying to find a stable fund for the subsidies if you may remember it was just a week ago that we witness the importance of three senators who did not experience mural dyslexia mural and dyslexia is the inability to read the writing on the wall and clearly their efforts helped to push back the healthcare Doomsday Clock for all of us we have a variety of challenges and and threats to improving our healthcare delivery system that represents over a trillion dollar industry and we're very concerned about issues such as the destabilization of the insurance marketplace we are very grateful to the California Health Care Foundation for their support of a series of talks including this one pertaining to health care reform and these talks are occurring here and a variety of community settings because so important to help inform the public about the complexities of this very important issue that touches all of our lives we're particularly happy that we've been able to partner at the UCSF Philip barley Institute for Health Policy Studies with the UC Hastings School of Law the UCSF UCSF Hastings School of Law consortium on law science and health policy and the Center for healthcare value which is also part of the Institute for Health Policy Studies we're very fortunate to have a wonderful panel of nationally renowned internationally renowned health policy experts who are also my very treasured colleagues and who will help to share with you some of the many issues that we need to consider so I want to briefly introduce you to you we could spend the rest of the time just talking about the history of these individuals but our first speaker will be Andy Biman who's a professor of medicine and health policy at UCSF he previously worked with the Energy and Commerce Committee with the US House of where he was intimately involved in the drafting of legislative language for the affordable care act he also recently served as the director of the US agency for Healthcare Research and quality and his many areas of expertise and research relate to Medicaid and healthcare workforce among many other topics next to Andy is dr. Jamie King who's the co-director of the UCSF UC Hastings consortium on science law and health policy and the executive director of the source on healthcare price and competition at UC Hastings College of the law as well as the co-director of the concentration on law and health science her research focuses on the drivers of healthcare costs with a special interest in market consolidation and efforts to improve transparency in healthcare pricing and last but not least is dr. Adams Dudley who's a professor of medicine and health policy at UCSF he's the director of the UCSF Center for healthcare value as well as associate director of research at the Institute his major research interests are in the area of quality of care and value-based purchasing so I'm going to be speaking we're gonna be speaking for about 40 minutes and then we'll have an opportunity for audience members to participate as well and I want to say that I think we should start off with the question of the fact that more than seven years after the passage of the Affordable Care Act or the ACA or Obamacare Republicans in Congress and President Trump had their much-anticipated opportunity to overturn this law and I think we should start off by talking about why is the ACA such a lightning rod and what is the difference in how Republicans and Democrats view federal healthcare policy well Claire thanks let me actually start off with that and then see if my fellow panelists have more to say about it but first of all it's a pleasure to be here this evening to have a chance to engage with with all of you you know I think this this public dialogue that's been going about the Affordable Care Act really reflects in one way the differences between politics and policy if it were just about policy I don't think we'd be having this kind of disagreement because after all the Affordable Care Act is really a pretty direct offshoot of the experiment that was first undertaken in Massachusetts to expand healthcare coverage and that was done under Republican governor Mitt Romney and you know so many of the elements of what the Affordable Care Act is about really were bringing together many ideas that were put forward by Republicans so it's not so much I think about policy in many cases but really does reflect a political decision that was made by many of the Republicans in Congress that it might be in their interest not to allow President Obama and his administration to have a win if you will in health care but I do think there are truly some differences in the philosophy of what is being attended to when health care reform is thought about by Democrats and Republicans I think for Democrats it really was about trying to address a social justice issue that for many years had been raised about there are problems with access to care and coverage of insurance coverage and so the Democrats of course really wanted to see health insurance coverage expanded and the Affordable Care Act has been quite successful in that regard we've seen over 20 million of the uninsured gained coverage since this law was passed so that's really the highlight from the Democrats point of view for Republicans I think there is a different priority that is put forward which is a concern about the fact that much of how this expansion happened was through an expansion of entitlement programs that were supported by the federal government and what entitlement programs have done to the federal budget in a sense what's happened over time is that more and more of the federal budget is accounted for by entitlement programs like Social Security Medicare Medicaid and now subsidies in the exchange and so forth and I think this brings a great anxiety to those who are very much prioritized fiscal concerns and so that really gets to the heart of a difference in terms of what priorities might be between Democrats and Republicans particularly when Republicans are also in Democrats as well recognizing that the demography of this country is aging and as a result the commitments through entitlements are only going to be growing over time so this I think is a very big deal particularly if you are prioritizing trying to control costs and at the same time we're thinking about on the Republican side that you would like to cut taxes to stimulate the economy so I think part of this battle is about differences in priorities Democrats really valuing a social justice agenda of increasing access and Republicans very much worried about what that will cost that's great and it's really important for Andy to bring up the underlying principles it's the kind of conversation that we should be having and there have been opportunities to have that that have sort of slipped away in in the current debate so for instance at one point talking about people with pre-existing conditions Moe Brooks from Alabama said if you've lived a good life you won't have pre-existing conditions and and that's a view of what illness is and how illness happens that that fits well with I don't think that an entitlement should be put in place for people to get health care because the people who need the health care have done something wrong and why should I have to pay for someone who's done something wrong and and that's actually a kind of underlying assumption that we really need to get at is that why we think as a society that illness happens are there exceptions to that and and if so how should we deal with those and if we accept part of that assertion then what does that mean you could imagine separate parsing that statement quite a bit and a kid born with a particular problem you can't blame them someone who's been smoking for a long time you could say well maybe they do have some responsibility but instead of having that kind of conversation we've had a very different sort of finger-pointing and a kind of conversation and we hope we can get to the root of things a little bit more tonight and going forward so thanks for giving us that background sort of the philosophical approaches so let's think about how that philosophical approach then has been translated by the GOP into its viewpoint into the policy what did Trump care turn out to be I think it's a great question it's one that we're still trying to figure out right it sort of depends on what day of the week it is turning out figuring out what Trump care is that at that particular time and I think some one of the big problems that they've had in this in this arena has been over the different factions in the Republican Party about what kind of agenda they wanted to put forward so you know Rand Paul really wanted to see full repeal and nothing short of full repeal would have would suffice Paul Ryan cared a lot more about limiting funds to Medicaid and reducing the entitlement program as and he talked about a little bit more others Ted Cruz really cared about limiting the amount of regulation on insurance plans and pulling back sort of the government hand that was guiding a lot of that and so having less control both over insurance plans and then other people wanted less control over individuals and thinking about the individual mandate and the employer mandate and requiring people to get insurance that they might otherwise not choose to have requiring certain things to be in plans that people maybe didn't want coverage for and then other people cared a lot about reducing the entitlements at put in as a part of the ACA in order to be able to give tax breaks and sort of forward their other agendas as we heard and so I think figuring out what Trump care really meant was a constantly moving target but I mean the main tenants of it tended to be reducing payments in Medicaid reducing spending Medicaid getting rid of the individual mandate and providing and providing extra funds for tax breaks and things like that but that seemed to be a lot of the main of the main focus even though the plans changed quite a bit I think the individual mandate is a really good place for us to think about and look at some of the problems with this by for more than bifurcate it's very splintered approach they Republicans we're taking because everybody had their problems with the ACA but when you're trying to pick off what they didn't sort of realize was that as you try and pick off those individual things the entire system the ACA sort of falls apart so you can't get rid of the individual mandate because you don't like the government telling that you have to buy insurance without recognizing the role that it's playing in the bigger scheme right and so Republicans never liked the individual mandate it's very much against Republican philosophy right but if you get rid of the individual mandate it affects the entire rest of the ACA right so the ACA in some respects you can't you can't have the popular provisions of the ACA which would be guaranteed issue it says that everybody can get insurance when you know if they want it and community-rating which says everybody pays about the same price if you don't have the individual mandate there to spread the risk and lower the cost across the board and so because there was so much because there was so much nitpicking at particular things it became very hard for the Republicans to nail down an agenda and a coalesce around one particular plan they all kind of wanted to pick off different things and and again that is so important not to talk about what the underlying philosophies are so most of what you just said we infer from what was done rather than statements going out we need to cut health care so that we can have other other tax cuts that was not said and and then the conversation got got even more confusing so at some point late last week people were saying people on the right were saying something they'd never ever ever said before or suggested was a good thing which is we already have universal health care and then they would follow that with anyone can go to the ER and get care if they need to and and it's a crucial moment in our or could turn out to be a crucial moment in our in our national health care debate because it asserts a very different underlying assumption it says many people on the right were saying perhaps influenced by the feedback that they've gotten about proposing to take insurance away we're saying no we have healthcare and the implication is and that's a good thing we have Universal here and that's a good thing so if that is a view that people on the right continue to back then it totally changes the conversation then you then you say okay well if everyone's gonna have health care is it the best way in terms of their clinical outcomes to send them to have them wait until they're sick and go to the ER is it the cheapest way to do it or is there another way that we could go about having universal healthcare where we got better outcomes for patients at a lower cost so what I mean we'll see what we got to figure out what the underlying issues are and we got to talk about those well clearly we anticipated some other kinds of outcomes with the election but I think it's really important to be thinking about what are the prospects for the ACA remaining intact or being repealed into the future well I think you know one of the big outcomes probably from last week of really the very dramatic vote in the Senate in which it was very unclear until the last moment what was going to actually happen there is that as they voted on different partisan bills and got skinnier and skinnier referring to the fact that it was just a smaller and smaller aspect of what they needed to try to change they still could not cobble together ultimately the 50 Republican votes in the Senate and so I think that was a not only a dramatic moment but somewhat of an embarrassing public moment for Republican senators and I think that will create something of a barrier going forward to continuing to try to do this kind of partisan approach to health care reform and even though we've continued to hear a little from the White House of you know take it up again do great things that it's gonna be I think very much less likely now that we'll continue to see that approach and you know why did this happen a little bit I guess I would say you know having been on the other side of this when the ACA was going forward I think we've had a president who is very much a cheerleader but was really not prepared to be a quarterback and I think that's just a very different set of roles during the ACA process I was exposed to seeing President Obama give the Congress a tremendous amount of flexibility of trying to shape something but at the end of the day the White House was very clear about how to coalesce and bring together disparate policies in a way so that it made a coherent sense and we have not had that I think in this attempt to unravel things that it is as Jamie was talking about picking off individual items but then what's left behind doesn't make any conceptual sense anymore and I think the inability of the White House to really sort of understand that know how to put together some kind of coherent plan has really undermine things so I do think that we're probably hopefully getting out of the phase of just a pure partisan no hearing kind of secret let's bring out the bill at the last minute approach but we may be shifting to something which might be quite reasonable for us to all be thinking about which is some kind of bipartisan approach to addressing either smaller parts of what needs to be fixed I think everyone has said including Senator Schumer that the ACA is not perfection it's was probably a very significant improvement over what had been the case in the health insurance marketplace before the ACA was in place but things still need to be addressed and I do think that there is now potential for some bipartisan approaches to move forward on specific things things like cost-sharing reductions which clearer reference which is going to be probably a very important part of helping to shore up things like exchanges like we have here in California of covered California so I do think there is a possibility of that it's going to take a while maybe for the leadership for Senator McConnell and for a leader a Ryan Tapp for the for for Paul Ryan to feel confident about allowing for some of these things to bubble up but I do think there's a possibility but I also think bipartisanship also is going to require that both sides be prepared to give up some of the things that they're holding on to most strongly if the Democrats mostly want to see improvements in affordability of health care coverage that is to make it more possible for people more people to come and buy in then they may need to think about whether they're willing to negotiate some of the strategies of bringing people in through things like mandates and are there other ways to accomplish bringing healthier people in I'm I think we can talk about what some of those strategies might be but I just bring that up that bipartisan approach probably is going to require truly some give and take on both sides we haven't really seen that process yet but I do think to move forward we'd be going back to kind of regular order of 60 votes in the Senate not the 50 and trying to pick off individual pieces so atoms I'm going to ask you a question specifically about one of the main arguments that President Trump has been giving for why the ACA needs to be repealed because it's really failing and these comments seem to be really focused very much about the health insurance exchanges for individuals who don't obtain private insurance through their employer is the ACA failing so again it gets back to what's important to you if what's important to you is to not have the federal budget rise and not to not create a new entitlement then yes the ACA is failing because a lot of money is being spent to give people more insurance if what's important to you is having everyone or almost everyone have insurance then it unquestionably it is not failing so for the first time recently 95 percent of American children had insurance so if that if that's your policy goal then then it's doing well if you look at specific news events a different story comes out so in the beginning of the ACA actually even before the website disaster which was an unmitigated disaster but even before that there were people President Obama had said if you like your insurance you can keep your insurance and there are a lot of people unhappy because it turned out that they know they could not keep their insurance and in fact they were gonna have to pay more and there was a rise in premiums but it's really important to understand why that happened so the ACA said that your insurance must have more features that protect you from financial ruin than previous insurance products that were out in the market so you couldn't have an insurance plan that kept what you were paid at $15,000 a year or what they would cover at $15,000 a year for instance and yet many of those kinds of plans were being sold and so people did have to pay more they could not keep the insurance plan that they had and and so that was a promise unkept and it led to dramatic increases in premiums because if the cap on what they're gonna pay goes from 15 to a million or something like that or infinite then then it's it's going to cost more subsequently there were further rounds of in some states further rounds of high premium increases this was a different kind of failing and it was a failing of the ACA the the reason the reason that that happened was because their expectation was that well there's a mandate and there's a penalty everyone will buy insurance and it turned out that the penalty wasn't big enough that all the healthy people would go ahead and buy insurance some of them said I'll just pay the penalty instead and that was a miscalculation about how big the penalty would need to be and so what happened was the insurers went into that thinking well we need to charge this to be able to cover the people who were gonna get but when they didn't get as many healthy people they had to raise it to say well we're not going to actually get all the healthy and so there was another round of big premium increases so that is another sort of internal to the ACA failure but then it seems like it has mostly stabilized out and so the failings that are being pointed out now are actually not from the original version of the ACA but from what's being done to the ACA right now so when you the the you've heard about the cost-sharing subsidies to the to the insurers and the the administration is saying we're not going to commit to paying those so now you're asking insurers to say what the price of insurance could be when they have billions of dollars they don't know if they're going to get or not get and so some are saying well we just can't play that game there's no way for us to win if we price it too low then then we'll lose a ton of money if we price it too high we'll be accused of being greedy and look what's happening to those people who say they're increasing their rates by 20% and yet if we don't price it high and we don't get the subsidies then we're really in trouble we might go out of business and nobody likes an insurance company's business so at the moment a lot of the problems are actually from how the law is written is being implemented given the importance of exchanges though for the American marketplace what do you think of some of the solutions what are some of the potential ways that we can get a handle on some of the problems that you've just clarified for us well so there's we need to figure out how to get if we're going to continue along the philosophy of everyone should be in whether or not you believe it's there in covering the cost of people in the emergency room or there in through everyone having insurance we have to find some way to have everyone pay because right now what's happening is that a or what was happening before the ACA is that a fair number of people were not paying in and then if they got sick they just went bankrupt and so any money that they eventually paid in was funneled through bankruptcy courts was incredibly inefficient and expensive way to get people to pay for things and many things that they that many debts that they owe never in the end did get paid so we have to come up with a better way to ensure that the healthy are in and stay in and then you've probably heard about the risk pools ideas and this concept of segmenting the market into people who have pre-existing conditions and and people who don't and that's something that we need to talk about in a meaningful way but the problem with the proposals that we've seen thus far is they said oh well take care of people with pre-existing conditions in these risk pools and here's the ten billion dollars or the fifteen billion dollars that they were going to do in the first year to do that when the estimates for what would cost to take care of those people were 178 billion dollars and so it's sort of a pretend risk fool and not a real taking on of that concept and and it might make sense it might be that risk pools are away say more government support to sick people at a real level so that the the premiums for the people who aren't yet sick can be lower maybe that would draw them in voluntarily or by mandate or whatever but if we don't actually try to do that if we say well what really is gonna happen is the there's not going to be that much money for sick people there then no one can stomach that and we can't have a real conversation because people are saying well you're basically killing off the sick people so hopefully will you have other ideas and about what needs to be done fixed I mean I think fundamentally you know what's underlying a lot of the Obamacare notion of exchanges is to create competition for health plans because competition actually will help to drive down costs and to get competition means you have plans that are willing to show up and feel confident about that they can at least keep their head above water in this marketplace so Adams is are referred to the cost-sharing reduction subsidies just to make sure everyone understands that this is this concept that those are between a hundred and 250% of the federal poverty level are relieved of co-payments deductibles coinsurance costs that would on top of premiums make it very difficult for them be able to afford to buy health insurance coverage and it is the case because of ways that the law is implemented that the administration has a lot of power to decide whether or not to continue that funding of course the Congress could come along and pass a law to make that really explicit and in fact they are talking about maybe trying to do just that because in fact many of the senators from both sides of the aisle don't see it in their interest of ruining the market of competition of insurers in their areas so number one is I think we need to stabilize competition and promote that through getting the cost-sharing reductions clear and available to help low income people come in there are also other things that can be done to make the marketplaces work better you've got a you know you got to advertise so you know many things go on in this country for example if you want to get a driver's license young people learn early on in our state and in most other states that to drive a car you have to have auto insurance and so they see the value of that we have no educational process in this country that helps people teach them about the value of health insurance and so therefore it's not a complete surprise that young people wonder about geez is that really expensive thing there is that just like an extra or is that really an important part of what it means to be part of a civil society and what my responsibility is in terms of paying in and so forth so we need to do a lot more marketing and help people understand also what the Affordable avenues are to be able to buy health insurance so that young people will come in and do that so the marketing needs to be positive and out there and then I think we also need to make sure that the products that are being sold really are providing what I'd call first dollar coverage that you don't pay in a whole bunch to get a premium and then on top of that when you go to use it you've got thousands of dollars of deductibles before you actually get the benefits of it we've been actually quite fortunate here in California that covered California has taken a very aggressive stance with regard to making certain things not be subject to the deductible like primary care visits so people can see the value of what they're getting when they buy health insurance and I think that's a key part of what needs to be improved in the regulation and implementation of what health insurance is all about and then finally we need to really recognize that there's a cliff right now that when you get there is help from the government to buy health insurance up to 400% of the federal poverty level but it turns out when you live in places like San Francisco as much as that sounds like it's a big amount of money you know how expensive it is here and how expensive it is in many parts of the country it just drops off in terms of the help that the government is offering you and we need to make a smoother landing going even beyond the four hundred percent of federal poverty level to make sure that people can find this product affordable so those are some of the things that I think could really help to make it more possible and to make health insurance companies feel confident about competing and not exiting the market because of the uncertainty the government is doing with regard to its support and implementation of this law the individual mandate has also been a creaky portion of making sure that people feel like their will will be a penalty if I don't play in this game but there's a lot of positive things that we can also do as to and try to encourage people to come in through education and other another strategies so this is why it's so important to talk about what really matters so the ACA is very competition based as the way it's set up it is actually very much based on ideas from the right and yet before the ACA with the ACA and certainly now we've had all this conversation about and fighting and sort of not very deep conversation shallow conversation and tweets this way and tweets that way about who's to blame and we aren't talking about why things are so expensive I mean the real root of why things are so expensive so anyone in here had a hip or knee replacement yeah I see some of those the the piece of metal that is now in you if you had gotten that in Vancouver it would have cost about a quarter the exact same piece of metal would have cost about a quarter what it costs in the United States we pay enormous amount more for each of the things that we get in healthcare and then we do a lot more of them and in a lot of situations it's known that they're not helpful and so that kind of conversation needs to have than two and we need to get off or get through somehow all this talking politics rather than policy and get to because people are really being hurt right now by not talking about policy and and there's actually much more grounds for agreement than people seem to realize just as evidenced by the fact of how very I mean the ACA structure came from the Heritage Foundation which is a right think-tank and was actually their proposal in response to the Clinton's proposal for for reforming health care so we gotta get to the right conversations as soon as possible so Jamie we talked a lot about the exchanges and I think it's important now to move and shift into thinking about really what is a big change in the coverage which has really related to the Medicaid program and what role does Medicaid play in our healthcare system and what are the key policy issues were likely to see debated in the days ahead you know I think a lot of the of the changes that the Republicans have put forward are are really based around Medicaid and the entitlements that it provides and I think that it's important for us to remember that Medicaid serves a huge portion of this country it's not just a program that is for you know very very low-income people obviously it qualifies that but 40% of babies born in this country their birth is paid for via the Medicaid program and Medicare we have a number of disabled individuals we have nursing home and people whose long-term care is paid for through via Medicaid and so it turns out to be a huge swath of the American public that is touched by Medicaid at some point in their life very often around the earliest points of life and very often towards the later parts of life and so Medicaid the Medicaid program I think it's very easy to just sort of think that this is just for you know people who you hear sometimes people say oh they choose not to work or they they're better off if they get Medicaid and so they don't want to take jobs it's a very M but it's really not true we're talking about a huge percentage of the American population and so I anticipate that through the Medicaid if if the Republicans are successful in repealing a lot of the Medicaid funds we are going to see a major turning back of the gains that we have made through the ACA and I think that that's a lot of what we're likely to see me we're gonna continue to see them trying to cut Medicaid and in a lot of different ways and I think it's important to realize that following the ACA if you cut Medicaid it's uncertain as to what's going to happen the various Republican pose proposals have suggested that they are going to cut between 15 and 22 million people off of the Medicaid rolls those are the estimates for those two proposals and if they do that a number of the number of the states about eight of the states that accepted the Medicaid expansion would immediately stop Medicaid expansion if the federal if the federal monies was reduced in any way and so those it's really important to recognize that the states are heavily involved in the Medicaid program and that individual people in individual states will be cut in that way in California alone I mean we have adopted portions of the ACA into our state laws that reflect how the medical program will result and it's really unclear what happens if the federal money that would be promised to California to cover the Medicaid program would but those dollars would be cut how would California pay for those things that we've now promised to our citizens and built into law and so I think that as the room as the federal government sort of tries to reduce its role I think we're likely to see a much bigger role for states to try and step into the health care space but also struggling to figure out how to budget for things when the federal government is not meeting the promises that it made and the states relied on you know I just to reinforce something that you're saying Jamie I mean the Medicaid program is the single largest transfer of money from the federal government to the states it is an enormous part of the lifeblood of the financing of states and that's why I think it was somewhat probably surprising in a way for many of the Republican senators who were first probably thinking this will be a slam dunk we're going to repeal the ACA to start hearing from the governor many of whom were Republican governors saying oh my goodness that's got to take away an enormous part of the financing of how we do things in our state and in our ability to cover to maintain our bond rating to be able to to borrow money at low costs and so forth so it's very significant to the lifeblood of states and I think there's an incredibly important policy moment now with it looking like things are really moving away from a dramatic legislative change at the Congressional level that there's another chance still for those 20 or so states still out there that have not expanded Medicaid that would bring about another five or six million people into coverage if they were to do that the majority of those by the way in Texas and Florida probably at least half of them are living in those two states alone but there are states I think that are very movable in terms of now maybe taking up the Medicaid expansion because sort of the political winds maybe kind of blew overhead and maybe it's going to calm down and they can actually do what is in their rational interests to finally do that and I think if there's anything that this policy fight showed about trying to repeal the ACA is when there are more states and people affected by this that suddenly there is an awareness of ah this actually does matter to me I mean what was so striking in this repeal effort was suddenly a law that for the longest time was kind of languishing just below 50% of the population saying I don't know I guess Obamacare is pretty good all of a sudden people woke up and said pretty good this thing is awesome and we don't want it to lose it because it's actually had an enormous impact on my personal life and coverage and so forth and that's why we saw a lot of people coming out to town halls and so forth and pushing back against this so I do think as a policy opportunity there is a window now that will open again where some states states like Virginia for example which has a Democratic governor has had challenges with the legislature their legislature they're accepting the expansion but I think we'll revisit this kind of opportunity and bring more people into coverage and I and I think that is something that is likely to be in play in the upcoming months or years I think you're exactly right and I think what we've seen from a lot of the states that have expanded Medicaid we're starting to see their budgets come in and showing that they are not in fact losing money at the rate that they were expected to you know that people said oh you're gonna lose so much money this is gonna be so expensive you're not gonna be able to do that and the data shows that that's just not what's happening that a lot of people have been able who were ill who are now getting care are able to go back to work and contribute more substantially to the tax base and so the data is coming in to show that the states that expanded Medicaid have are winning with doing that and that it's been a very successful and move for them and so I think if we can get the political climate to stabilize substantially so that we're not constantly threatening to repeal all this at any moment I think that we will see a lot of states come back and support Medicaid and and engage in the expansion and if they don't take the full expansion they're likely to take apply for a section 1115 waiver where they can modify it slightly and a lot of Republican states have had great success doing that politically it's saying well we don't we don't want them the expansion just as they wrote it we're gonna tailor it a little bit so it's a little bit more palatable and that has been really successful in getting people coverage in those states as well well obviously all of these topics are extremely important and as you prepare for some of the questions you might want to give to the panel I want to end by asking you a slightly different kind of question which is how has the attempt to the repealing of the ACA made single payer more or less likely in our future and could it be part of a solution to provide high quality lower cost care and maybe each of you can make some brief remarks and then George will walk around with a mic so Andy do you want to start yeah sure I mean I think when we are talking about things like health care costs it would be foolish of us not to consider what something like single-payer has to offer to us I think there is evidence from other countries and even within our own country through programs like Medicare which by the way is a single-payer program for the age of 65 and what the one of the major benefits of a single payer program is that it is administratively less costly to run that program and that is a source of savings that does not have any direct impact on the care that's provided so I do think it's it's a critical thing it's also make you know you can understand from my from a political point of view why this has resurfaced that I think you know many on the Left probably have been kind of holding their fire for a while and kind of following a political strategy of trying to tack toward a more moderate position hoping that that would sort of hold this the center and be able to retain control but you know with the election of President Trump and what seems to be a fairly sharp drive to the right those on the Left are saying wow if an extreme view on the right can work for their team how about we try going more extreme to the left on our team and I do think you will see that kind of pendulum activity we're seeing it in states like California and others where there is that being raised to the surface but there are real things that come up that are impediments to moving that forward things like wow well does that then require for example the help of the federal government to bring the Medicare and the Medicaid dollars into that single-payer strategy a state may use and you know at a time like this it's a little hard to imagine how our state which is colored very dark blue would be able to get those kinds of permissions from from Washington DC right now which seems to be more intent on trying to gum up some of the policies that we're putting in place so I think there are real political barriers to being able to do this but I think it's a healthy issue to be raising to be able to look at are there ways that we could have obtained savings from reducing administrative costs I think without question all this debate about health care has caused I mean all this action around health care has caused a lot of people to start thinking about health care and why is it that we don't get it this way and it's really raised the public consciousness and so when we it also causes people to look abroad and see that other countries don't seem to have quite as many problems they have their struggles but they don't have this the same kind of debate as we do and so I think it really has raised issue and the question of single-payer to the forefront of a lot of people's minds and what we've seen is that we've seen a lot of interest in single-payer and Bill's initiated in a number of different states around the country obviously Vermont was the first and then we've had a bill in New York and in California and in Nevada and unfortunately just like the Vermont bills none of those Bills have had have had any you know have had a success so what's happened is the California bill passed the State Assembly but died in the Senate right new york's bill there it was proposed but there hasn't been much movement on it at all and nevada the bill got through the legislature and then the governor vetoed it on the end so we're starting to see some progress in states but not not it hasn't gotten very far and usually the sticking point with single-payer is when people see the price tag right they think oh my god we're gonna have to pay this much extra in taxes and I think the the point that as Adams keeps saying the point that we really need to be having discussion around is that yes you're going to pay more in taxes in a single-payer bill but you're not gonna be paying a lot of other things so you're not going to be paying the incredibly high health insurance bills that you historically have paid we're gonna cut the administrative costs from health care we're gonna caught both the you know the insurance companies profits that are coming off the top of those things that depending on the way that bill is structured but there's gonna be a lot of savings and the other thing that I think we really need to make people aware of is the fact that you are paying for the health care of the uninsured and the underinsured you're just paying for it in the most inefficient way humanly possible it's you're doing it and so once you make it clear to people that oh by the way your hospital bill or your kids trip to the pediatrician or whatever it is is you know twice as expensive as it would be to make sure that you know that provider or that state you know has enough money or your taxes are higher to make sure that we have enough money to cover the the care for the uninsured and the underinsured if we can compare those costs that people don't think about and say this is how much you're paying in taxes look how much less of it actually is I think that's when we can start to have a real conversation about single-payer being viable so it's going to take a lot of work but I think it's a good place to start and I'll just first make clear that I'm not sure single-payer is the place to go when I was I did some research in the 1990s with the VA system which is like single payer for veterans and we showed that when they went through a process of reform and and implemented better management and electronic records and stuff like that that they dramatically improved the quality of their care and they went from use data from a sample across the nation they went from worse than by quite a lot worse than the national average to by quite a lot better than the national average and I went around presenting this data in Washington and other places and and somebody got up and said well doesn't this prove that single-payer would be better cuz look how the VA is better and I said well but which single-payer are we talking about are we talking about the VA single-payer from before the reform that was worse than the market system or the single-payer from after the reform that was better and and we have to figure out how we're gonna run a healthcare system no matter who is paying so that you get the best possible outcomes that said I might answer to the I mean your question was has something about this debate made single-payer more or less likely and so whether or not it's the way you want to go I think that yes absolutely this debate has made single-payer more likely because we dangled out there the possibility of taking it away taking healthcare away from tens of millions of people may still do that but in any rate people will see it will be made obvious that the big immediate impact hopefully people will listen to the the effect of that we see in the bank bankruptcy rate so the bankruptcy of them way down when we covered more people because more than half of bankruptcies before the ACA were related to healthcare problems I have the question that goes back to dr. Dudley's point about hip replacements and now let's just make believe that we get past the politics and the the policy issues and deal with what I think was supposed to be the next step after the ACA and that was dealing with health care costs and the efficiency of of delivering medicine so what is the first step to take if we want to tackle that and is it a policy decision the political decision or a professional chore to tackle that the first step is to talk about it and talk about its real causes so and there are some and this is why I want us all to talk together that the Republican had new Republican head of the FDA is taking a very interesting approach that we should seriously consider to drug costs he has said that he wants to speed up the approval of generic medications so there will be at least three generics in every drug category so that there can be more competition well raise your hand if you've had trouble with drug Koster you know somebody who has the average amount that we're spending now for every man woman and child in America on drugs is up to $1,000 a year so we have to seriously consider why are drugs so expensive why are they so much more expensive here in the United States than they are in other places you'd be perfectly happy to live so I'm not saying they're cheaper in poor countries they're cheaper all over Europe they're cheaper anywhere that you you know is a developed country and so what are the what are the ideas that we need to consider an experiment with to figure out whether or not we can do things better that on the surface of it that at least three competitors is a good idea but there actually are some generic drugs where we already have eight competitors and they seem to be shadow pricing each other by which I mean one goes up a little and the other goes up a little and and so it may be that we need to do something more to stimulate competition besides just have a number of competitors but there's no way around the fact that lots of places there's only one generic available and that and the manufacturers have figured out well why would I price really low if I could price really high I just have to be a little cheaper than the brand and lots of health plans and lots of states even have laws you must use the generic so if I'm 90 the price I mean there used to be 10% of the price of the brand or something like that now I can be much closer to the brand price and if I'm the only one here no one has any choice so the idea that the that the FDA is pursuing is certainly worth considering but there's also some evidence that it might not be enough and so what else do we need to consider at the same time so I think I think the comments on on drug pricing are really important but I think also it's important to recognize that drug prices are a fraction of what we spend on healthcare overall and are and I think that we really need to look at what's driving healthcare prices up so substantially we pay more than any other country by a long shot in terms of our overarching health care prices and there's evidence to suggest that that is being driven that is being driven largely by consolidation in the healthcare provider state in the healthcare provider markets and so we need to be thinking pretty clearly about ways to promote competition in those markets ways to break up conglomerates bigger health systems that are driving up costs we're recognizing that you know there was a long time where the FTC and DOJ did not pursue healthcare mergers that were happening and they were health hospitals weren't able to merge inform health systems and hospital systems that have now started to acquire provider groups and provider groups within market and provider groups without outside of market and we're recognizing that those are now driving costs up substantially and so to the extent that we are interested in having a market-based approach we need to start thinking very very seriously about how to make that market work and if it can't work and in places where we don't have the ability to insert competition we need to start thinking about whether rate regulation is appropriate in some places and I think that you know this is America may like our you like our market-based economy but it's failing us and it's hurting American businesses and it's hurting American consumers and if we want to if we want to really talk about costs we need to put all policy options on the table and that bit about the lack of competition is actually one more thing we should have been talking about all along and it comes from a very good place it's not just people going out there trying to be greedy and be able to charge more the ACA is part of what it was trying to do separate from the insurance but it has a whole bunch of things that say we want you to coordinate care better and so people look around said well how why are where my coordination care problems well the hospital doesn't tell the primary care doctor what's happening and the specialist doesn't know from either one of them and so there was a lot of consolidation trying to improve the flow of information and with a very good clinical rationale or I need to have more I'm a hospital I need to have more doctors over there on that part of the map where I don't and when the patients who comes from me from there goes back there I don't have anyone I know how to talk to and so there was a lot of people buying up other people with a clinical reason to do it and then it turned out that after not very long you could only have you know one or two or three really integrated groups in in a lot of parts of the country and so then they had no reason to be careful about their prices because they had half the market no one could leave them out how would a single-payer system affect the Kaiser system you know probably any company that's involved in I mean Kaiser is partially an insurance company and so if in fact we're talking about in single payer changing the aspects of how money is collected that could have clearly an impact on Kaiser because they are involved in that business but I do think your question has a deeper aspect that we should all reflect on a little bit specifically related to the bill that was put forward here in California and has been thought about in other places a single-payer system is partly about how do you collect the money in from people and then it also has the part of how do you pay it out I mean this is a decision that frankly all insurers have to make a decision about I think historically single-payer has been thought about as a single collection say by the the the government and then paid out fee-for-service and I think something that's really evolved pretty dramatically since that first concept was raised is how we pay it out the fee-for-service system is pretty clearly behind some of what the health care cost growth has been about because it very much drives volume rather than value that right now any provider who does more stuff whether it's appropriate or not is going to get paid more money and one of the great benefits of something like a kaiser or any system that takes responsibility for a population is that it starts to make more strategic decisions about how it uses and pays out its resources so I think you know really where a more sophisticated discussion of single-payer might end up needing to go to is how do we get the administrative benefit of how we collect the money in but then think about the benefits we've also learned from being able to then redistribute the money out that is focused on efficiency of how we take care of populations which is what I think Kaiser has taught us a great deal about here in California as have some other responsible plans in terms of how they've done things and that is embedded in fact in part in the Affordable Care Act through things like a COS which is also trying to move providers more toward this mindset of taking responsibility for a population and using the resources efficiently so you know as the bill that was put forward in California that would have been very bad for Kaiser but I think there are more clever ways to think about how to administrative Leiby efficient of collecting the money in efficient and how we redistribute it back oh yeah I actually think Iser do great so that so Kaiser isn't one thing Kaiser is actually three things it's a medical group that's the doctors it's Hospital chain and it's an insurance plan so obviously if the government takes on the insurance function the people who work for the insurance plan have a problem but but most by far of the people that Kaiser are on in the Medical Group side and the hospital side and that care to the extent that they could say well people who come to us expect us to cover everything for them they can really manage that budget and if they're facing a single-payer who says we want you to do this for the lowest possible budget then Kaiser has all the pieces already in place so I actually think a single-payer could work out great for Kaiser so if you say the single-payer is bring the money in and then dole it out in a way that focuses on the budget then Kaiser could start doing that and I think has all the pieces to it well if the Congress actually does bipartisan fix to various elements of the Affordable Care Act and gets through the senator than the house what's the possibility that president Trump would veto that simply on the grounds that he's opposed to anything that President Obama produced I think that's is a fascinating question to imagine republican-controlled chambers of the Senate and the house both agreeing to something and then the president vetoing it not an impossibility with this particular president but you would think that somehow he would recognize what the underlying politics of that are but you certainly late laying out a scenario that doesn't seem impossible given what we've experienced thus far yeah I don't think anything's impossible with this pregnant president but I do think that he has demonstrated an ability to pivot I think it's quite likely he would he would say this is an amazing thing that have come out of the Republican House and the Republican Senate and declare victory and go home so I want to thank our wonderful panelists and I also want to encourage you to look at the UC Hastings School of Law the healthcare tracker which can provide to you a great deal of wonderful information it's kept up to date as well as the Phillip arleigh Institute for Health Policy website and on that note I want to say thank you very much for all of your wonderful responses and for you all to be here [Applause]


  1. Fairly thorough. The issue of unnecessary healthcare treatment and procedures was not discussed including tests, surgeries, etc.
    Should taxpayers continue to pay for chiropractic 'procedures'? Acupuncture?

  2. To anyone wondering if this video key points. while slightly liberal (certainly not quack level) video goes into how:
    why obamacare ended up charging some people more
    why not everyone was covered
    obvious problems with obamacare with possible solutions
    who actually gets "free" healthcare spoiler not as many as you would think
    why repeal failed previously. how it might work
    why things are so expensive: cause all the free healthcare? no US is obviously an industrialized country thus prices are higher. More procedures are done (even though they are probably useless) driving up demand thus cost
    lots more

    As a side note people do know that Obamacare was strongly based of the old plan from the right? So just being political and hating on this video for being "liberal" is pretty ignorant * see below. hope ya watch and learn something

  3. I'm sure liberal quacks from the leftyverse will give an unbiased and fair accounting of anything Trump does 😀

  4. Are you [email protected]#%@#G kidding me? Trumpcare? REALLY?

Leave a Reply

Your email address will not be published. Required fields are marked *